Standardized Student

Helping a Student to Think Clinically Through Questioning

General description of the problem

Betsy Hummel is a 22-year/old MS3. Betsy has done very well in the basic sciences and is now on your rotation. This is her first clerkship. This is the third week of the clerkship and by now, most of the students are getting the hang of what the service and the ambulatory center are all about. You are the attending [or resident] to whom Betsy is assigned. Right now you and she are in the clinic, and she is about to present her first patient of the day to you.

Standardized Student - Betsy Hummel, MS3 FP or IM Clerkship Script

1. the importance of helping students think through a problem so that they can make a commitment to some kind of diagnosis;

2. to use a two level questioning process which focuses on closed ended questions (for facts) and open-ended (assessment of your (THE STUDENT'S) understanding, problem-solving for diagnosis, and management development for treatment and management)

1. GENERAL PREPARATION INFORMATION FOR THE STMS:

• You present data only

• Wait for RESIDENT OR ATTENDING to ask questions

• Follow the lead of the RESIDENT OR ATTENDING

• BECAUSE YOU ARE AN M3, You have minimal clinical problem-solving ability at this point in your career.

• WHILE YOU SHOULD HAVE RELATIVELY GOOD BASIC SCIENCE KNOWLEDGE, You have minimal clinical knowledge and even less clinical problem-solving abilities, SOMETHING WHICH IS NATURAL FOR YOUR STAGE OF DEVELOPMENT.

2. YOUR General Behavior AND Demeanor

You appear very unsure of what is going on with this patient. You are very insecure as a third year student. At first you thought that this patient had gastroenteritis, but the more you talked with her you realized that was wrong.

You already know that your resident/ATTENDING (and he/she is the person to whom you are assigned for the duration of the clerkship) has been short with you when you get things wrong. You don't know if he/she is just trying to push you to do better or is trying to pimp you! YOU KNOW HE/SHE WOULD LIKE YOU TO MOVE FASTER AND TO SEE MORE PATIENTS BUT YOU JUST DON'T FEEL LIKE YOU KNOW ENOUGH. You therefore are very frightened to disclose your unfamiliarity with this case problem.

3. Answers to specific questions

• Compiling: you lack the ability to join together the various elements of a clinical evaluation; IN ORDER TO BEHAVE THIS WAY YOU MUST THINK DIVERGENTLY BUT NOT SHOW MUCH ABILITY TO RECOGNIZE PATHOPHYSIOLOGICAL RELATIONSHIPS

• Linking the data to diagnostic hypotheses pertinent to the chief complaint IS WEAKLY DONE

4. Here is what you describe

Came to clinic in severe distress with extreme pain in lower abdomen with noticeable low back pain.

Hx of a low-grade fever for past several days, but has not taken temp. You confirm that she does have 99.5oF.

Finished her period three days ago. Uses heavy flow tampon. Is on BC pills.

Some emesis; 2x in past two days.

Pain is bilateral (abdominal exam). Some guarding and rebound tenderness. Bowel sounds are present. (If you are asked if bowel sounds are hyper, you haven't heard enough bowel sounds to know yet.) No masses felt.

[FYI: high fever, leukocytosis and copious purulent cervical drainage are commonly associated with PID, but low-grade fever, mild to moderate abdominal pain, irregular bleeding and vaginal discharge may also signal the disease. This is what you have missed…- teacher to work through this with you.]

When asked here are:

CC:

Severe pelvic pain

DDX:

pause, blank look, etc. You can't think of anything. When pushed you guess gastroenteritis, appendicitis, ovarian cyst, and ectopic pregnancy. But the latter you really know is "wrong", because Ms. Hayes just had her period.